Rigid Bronchoscopy for Diagnosis and Treatment of Proximal Pouch Fistula in...

Even when rigid bronchoscopy is performed routinely prior to repair of presumed esophageal atresia with distal tracheoesophageal fistula or type C, proximal fistulas or type D atresia can still be missed. These fistulas are often subtle and look quite different from the distal fistula. This rigid bronchoscopy video will demonstrate a case of a missed proximal fistula and its attempted endoscopic treatment. A term male with presumptive esophageal atresia and distal tracheoesophageal fistula underwent repair through a right thoracotomy on the second day of life. A rigid bronchoscopy was performed just prior to the repair and was interpreted as showing a distal fistula 1.5 to 2 centimeters proximal to the carina with no other anomalies. The patient had an uneventful immediate postoperative course. A routine esophagogram performed 6 days after repair showed a tracheoesophageal fistula, despite the absence of a leak or significant stenosis. The possibility of a missed proximal fistula was entertained, and the patient subsequently underwent a rigid bronchoscopy a week later to minimize the chances of traumatizing the recently ligated fistula. The site of the previously ligated fistula can be clearly seen. A subtle fold is seen approximately 1 centimeter proximal to the distal fistula site. Attempts to pass the thin suction catheter through this fold are unsuccessful. A glide wire is subsequently easily passed through this fold, confirming the presence of a proximal fistula. The glide wire is used to stent the fistula open as the tract is cauterized with the bugby cautery. This is continued until the tract and fistula wall are fully cauterized. The proximity of the two fistulas can be seen in this view. Following cauterization, the extratronomer hyaluronic acid copolymer, or Dflux, is injected into the tract. The glide wire is subsequently removed and the procedure terminated. Unfortunately, the procedure was unsuccessful, and the proximal fistula was still patent on an esophagogram two weeks later. The patient subsequently underwent successful repair through a right neck incision, as shown here. This case emphasizes the difficulty of identifying proximal tracheoesophageal fistulas. If any suspicion is seen on rigid bronchoscopy, insufflation of air through the esophageal pouch or installation of methylene blue may help confirm a proximal fistula.